Flipping Tickborne Illnesses with Infographics

Audience This interactive module is designed for implementation within an Emergency Medicine Residency program. The target audience is post-year-graduate one to post-year-graduate four residents, medical students, physician assistant postgraduate trainees, physician assistant students, and physician assistants. Introduction A knowledge of tickborne illness represents a critical component of infectious disease education for Emergency Medicine residents. Ticks that harbor these organisms are highly endemic to the continental United States and zoonotic infections are a critical differential diagnosis in the evaluation of patients in the Emergency Department.1 There is significant morbidity and mortality associated with tickborne diseases, and many of the signs and symptoms can mimic other common presentations. While these illnesses can present a diagnostic challenge and coinfection does occur, treatment is generally straightforward and readily available.2 An understanding of vectors and rates of transmission in a geographic area can foster a high clinical suspicion and ensure that effective treatment is administered.3 Educational Objectives After participation in this module, learners will be able to 1) list the causative agents for Lyme Disease, Babesiosis, Tularemia, Ehrlichiosis, Anaplasmosis, Tick Paralysis, Rocky Mountain Spotted Fever, and Powassan Virus, 2) identify different clinical features to distinguish the different presentations of tickborne illnesses, and 3) provide the appropriate treatments for each illness. Educational Methods This module utilized the flipped classroom model of education for independent learning, along with small group discussion as the in-class active learning strategy. Learners independently completed pre-assigned readings and questions based on the readings. In didactics sessions, learners created an infographic of each of the tickborne illnesses. Each infographic was shared with the entire group in the final 30 minutes of the didactic session. Research Methods Each learner completed a pre-test prior to receiving the educational preparatory materials. At the end of the session, participants completed a post-test, a Likert scale survey to evaluate the program, and a free text box to provide qualitative feedback on the session. Efficacy of the education content was determined by post-test scores. Results Unfortunately, the pre-test file was corrupted by a virus and inaccessible, resulting in no comparison data. A post-course test of 4 questions and a Likert scale evaluation was completed by 22 participants. 72.7% of the participants felt the session increased his/her knowledge on the topic, and 59% enjoyed the format of the session. Fifty-percent of the participants missed zero post-course test questions, 27% missed one question, and 22% missed two or more questions. Comments for improvement suggested a better explanation on the use of software to create the infographics. Discussion The post-course test and evaluation suggest the session achieved positive Kirkpatrick levels I and II of evaluation, was effective, and the objectives were met. Based on comments for improvement, information on the infographic software should be provided ahead of the session. This session has become a regular part of our 18-month residency didactic curriculum. Topics Infectious disease, tickborne illness, zoonosis, flipped classroom, infographic, cognitivism.


Linked objectives and methods:
Traditionally, didactics have been delivered via an hour-long lecture format. There is little data to support this as the standard form of information delivery. 4 In the lecture format, learners are in a passive state, receiving information. 5 For this session, we desired to have learners engaged in active learning and discussion. In order to achieve this, we utilized a flipped classroom with a small groups format. Two weeks prior to the scheduled didactic day, learners received preselected readings and a list of open-ended questions to answer based on the assigned readings. On the didactic day, learners were divided into eight different groups based on level of training with the goal of evenly distributed experience across each group.
Once divided into groups, each group was assigned one of the eight types of tickborne illnesses included in the pre-readings. Each group then created an infographic on that assigned illness. The infographics included salient information such as risk factors, vectors, presenting signs and symptoms, diagnostic testing, treatment, and complications (objectives 1, 2 and 3). The format of an infographic allowed for integration of the required information into an organized, creative, and visually stimulating representation of each illness. Infographics have been successfully used in education not only when used as the main teaching tool by educators, but also when learners have created them as part of their learning. 6 Groups were given 45 minutes to complete the infographic. In the remaining time, the groups presented their infographics to demonstrate their learning and reinforce teaching points to the rest of the groups participating in the session.
Cognitivism is the main educational framework that guides this didactic session. In cognitivism, learners are asked to receive, process, interpret, and assign information. 7 In this session, learners receive information in the pre-didactic readings. The processing, interpretation, and assignment of information occurs in the creation of the infographic. This learning is further reinforced when each group presents their infographic (objectives 1, 2 and 3).

Recommended Number of Learners per Instructor:
This is an asynchronous module, not requiring moderation in real-time.

Objectives:
After participation in this module, learners will be able to:

Results and tips for successful implementation:
A pre-test and post-course test and evaluation measured this didactic at Kirkpatrick levels I and II. 8 The pre and post-test consisted of the same 4 multiple choice questions. Four questions were included to keep the overall number of survey questions low to aid response rate. The post-course evaluation included a Likert scale in addition to an open text box to provide qualitative feedback comments.
A total number of 22 learners participated in the didactic session. Unfortunately, the pre-test file was corrupted by a virus and inaccessible, resulting in no comparison data. The post-course test and evaluation was completed by all 22 participants. Seventy-three perecent of the participants felt the session increased his/her knowledge on the topic, and 59% enjoyed the format of the session. Fifty percent of the participants missed zero post course test questions, 27% missed one question, and 22% missed two or more questions.
Open text box suggestions provided varied comments. Most learners commented that they enjoyed the didactic session. One comment suggested receiving the prereading materials earlier than two weeks but did not offer an exact time. Most critical comments suggested a better explanation of how to use the infographic software. One group had technical challenges using the software and felt they wasted time figuring out the software when they could have been working on the assignment. In the future, we plan to send a link of a video on how to use the software prior to the didactic session so learners have time to familiarize themselves with the software. Familiarity with the program may also ensure that the exercise can be completed in the allotted 45 minutes. All the information required to create the infographics is available in the pre-session questions; thus, time spent on searching for salient information is greatly decreased if particpants prepared for the session.
Also, given the availability of the online platform, the notion of creating a portion of the infographic asynchronously could allow more time for in-class discussion; however, working in small groups outside of allotted conference time may be logistically challenging. Providing an example infographic could be another means to portray expectations and increase the efficiency of the process.
Lastly, each program is able to cater this session with regard to time and group numbers to their needs. Although we utilized 45 minute sessions and eight small groups, other programs may wish to allot additional time for the creation of the infographic or consolidate groups to a lower number of groups.

Pearls:
Learners receive the answers to the worksheet they were required to complete prior to the session. No handouts were given.